FOR DMV USE ONLY

APPLICATION LIVE SCAN

A Public Service Agency
DPE COMPLETION DATE EFFECTIVE DATE

EMPLOYER TESTING PROGRAM CLASS APPROVED FOR APPROVED BY

EXAMINER CERTIFICATION APPLICATION

CHECK NUMBER PRESENT DATE

EXAMINER NUMBER DATE LETTER SENT

EXAMINER’S NAME DRIVER LICENSE NUMBER

MAILING ADDRESS CITY STATE ZIP CODE

STREET ADDRESS CITY STATE ZIP CODE

WORK TELEPHONE NUMBER OR HOME TELEPHONE NUMBER

( ) ( )
CLASS OF DRIVER LICENSE ENDORSEMENTS NUMBER OF YEARS PRESENT CLASS CDL HELD BIRTHDATE

REQUEST TO ADMINISTER THE

Class A non-passenger (tractor-trailer) drive test

Class A passenger (trailer bus) drive test
Class B non-passenger drive test
Class B Bus 11-15 passengers, including the driver, drive test
Class B Bus, 16 or more passengers including the driver, drive test
EXAMINER TRAINING DATES REQUESTED - FIRST CHOICE LOCATION

EXAMINER TRAINING DATES REQUESTED - SECOND CHOICE LOCATION

I WILL BE CONDUCTING DRIVE TESTS FOR

EMPLOYER NAME ADDRESS CITY STATE ZIP CODE PHONE #

California state law allows the California Department of Tax and Fee Administration and the Franchise Tax Board to share
taxpayer information with DMV and requires you to pay a delinquent state tax obligation. Failure to pay this delinquent tax
obligation may result in suspension of this license.
I certify under penalty of perjury under the laws of the state of California that the foregoing is true and correct,
and that I am the examiner for the above named employer(s), and have the appropriate class of commercial driver
license with any appropriate endorsement(s) and/or restrictions as required to operate my company’s vehicle(s).
EXAMINER’S SIGNATURE DATE

DL 811 ETP (REV. 10/2017) WWW Print Clear Form

The Department of Motor Vehicles will use the information on this application to determine if you are
qualified to conduct the required commercial drive test for the issuance of a Certificate of Driving Skill
(DL 170 ETP) in compliance with the California Vehicle Code §15250 and Title 49, CFR, Part 384.
Information submitted is subject to verification by personnel of the Department of Motor Vehicles.
Prior to receiving authorization to participate in the Employer Testing Program, you must meet the
prerequisite criteria listed below. When all of the prerequisite criteria have been met you will be eligible to
attend the required Driving Performance Evaluation (DPE) Training and take the necessary Proficiency
Tests in order to obtain Examiner Certification. A fee of $150 will be collected for DPE Training.
The following criteria must be met to qualify as an examiner:
• Complete an Employer Testing Program Examiner Certification form, (DL 811 ETP).
• Submit fingerprints at a California Live Scan facility on a Request for Live Scan Service
form, (DMV 8016).
• Submit the second copy of the Live Scan Service form, (DMV 8016) with the Employer
Testing Program Examiner Certification form, (DL 811 ETP).
NOTE: Examiner certification will not be granted if the live scan results reveal:
— A felony conviction within the last ten (10) years.
— A conviction involving fraudulent activity.
• Have a valid commercial driver license for at least three (3) years, with the appropriate
class and endorsement, for the class you will be testing.
• Have a valid California commercial driver license with appropriate class and endorsements
for the requested testing authority.
• Have no disqualifying actions against your California commercial driver license.
• Have a valid Medical Examination Report on file with DMV.
Please return the completed Employer Testing Program Examiner Certification form and the second
copy of the Live Scan Service form to:
Department of Motor Vehicles
Occupational Licensing, ETP Unit
PO Box 932342, MS L224
Sacramento, CA 94232-3450
You will be notified by mail after the DMV evaluates your application and determines your eligibility
to attend DPE Training. Applicants must attend DPE Training and pass the Proficiency Tests before
certification is granted.

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DL 811 ETP (REV. 10/2017) WWW